Review of Maternal-Infant Review of Maternal-Infant Nursing Nursing

徐丽华上海交通大学护理学院

2006－ 4－ 27

Trends in Maternal-Infant Trends in Maternal-Infant Nursing CareNursing Care

Development standard of care, certification, advanced practice nurses

Home Health care for postpartum women, discharge from Hops. 12-24 hours after delivery, high risk infants discharge home earlier than before

Consumer involved in the childbearing care: Child birth class, sibling present, breast-feeding, birthing environment (LDR, LDRP), father’s involvement, parents leave option for family with newborn

Maternal Nursing concerns areasMaternal Nursing concerns areas

Prenatal care Low birth weight Mother and infant with HIV infection Adolescent pregnancy Drug and substance abuse during pregnancy Social/family stress and impacts to pregnant

women and family Use and care for pregnant women

Special Issues in Women’s Special Issues in Women’s Health Health

Violence Sexual Transmitted Diseases: HIV/AIDS 86% of pediatric AIDS cases are

transmitted through vertical transmission of HIV

Substance abuse Other diseases: Heart diseases, cancer,

osteoporosis, eating disorders

The Menstrual CycleThe Menstrual Cycle

Ovarian Cycle: 1. Follicular phase: stimulated with FSH to promote

the development of follicles Estrogen-follicle mature-negative feedback to

hypothalamus and anterior pituitary gland – inhibiting FSH secretion

2. Ovulation: increase in body temperature (progesterone secretion), fern pattern of the cervical mucus, spinnbarkeit “elasticity of the ovulatory”due to secretion of the estrogen

The Menstrual CycleThe Menstrual Cycle

3.Luteal Phase: Corpus luteum and anterior pituitary gland will secret luteinizing hormones (the decrease in Estrogen and progesterone – positive feedback to Hypothalamus and anterior pituitary- stimulating the secretion of FSH

4. Premenstrual phase: Decline in estrogen and progesterone

The Menstrual CycleThe Menstrual Cycle

Endometrial Cycle:

1. Proliferative phase

2. Secretary phase

3. Menstrual phase

QuestionQuestion

FSH stimulates which processes in the menstrual Cycle?

a. Thinking of endometrium

b. Maturation of follicle

c. Decrease in basal body temperature

d. Increase in progesterone production

Infertility CareInfertility Care Infertility affects 15-20% of the populations in the

reproductive yearsTerms to be understood:

1. Artificial insemination2. Endometriosis3. Laparoscopy4. Primary Infertility5. Secondary Infertility6. Varicocele7. Endometriosis

Terms related to Infertility Terms related to Infertility TreatmentTreatment

In vitro Fertilization/embryo Transfer Gamete intrafallopian tube transfer (GIFT) Zygote Intrafallopian Transfer (ZIFT) Testing of infertility:

1. Ovulatory Analysis 2. Sperm Analysis3. Testing of STDS4. Tubal Patency test

QuestionQuestion

In which phase of the menstrual cycle is thick, scant cervical mucus and an elevated BBT seen?

1. Estrogenic phase

2. Menstrual Phase

3. Ovulatory phase

4. Luteal Phase

Names of the infertility drugsNames of the infertility drugs

Clomiphene “Clomid”-risk of multiple ovulation hCG: to facilitate the ovulation , side effect

ovarian over-stimulation hMG + Menotropin: Human Menopausal

gonadotropin Danazol: suppresses ovulation and secretion of

FSH and Luteinizing hormone to inactive ectopic endometrial tissue. Side effect-Wt gain, hot flashes, decreased breast size, vaginitis

Nursing care for infertile Nursing care for infertile couplecouple

Identify problems and strengths: Self-esteem disturbance related to

diagnosis Personal Identity disturbance, related to

unsuccessful infertility treatment Ineffective family coping, compromised

live and decision making Nurse =supporter, advocate, counseling,

Pregnancy TerminationPregnancy Termination

Legal/ethical Decision making dilemmas Counseling regarding pregnancy

terminationPsychological impact of pregnancy

termination Risk and complication associated Grief/guilt/ambivalence/uncertainty feeling

after terminating of pregnancy

Sexually Transmitted Sexually Transmitted DiseasesDiseases

Chamydia trachmatis infection Gonorrhea Human Papillomavirus Herpes Simplex Virus type 2 infection Cytomegalovirus infection Syphilis Vaginitis Human Immunodeficiency Virus Infection

QuesitonQuesiton

Women should be taught to be aware of early warning signs of HIV infection which are:

a. Dyspareunia

b. Severe dysmenorrhea

c. Occasional Candida infection

d. Recurrent episodes of genital warts

QuestionQuestion

The purpose of taking Tamoxifen after a mastectomy is to:

a. Alleviate cancer painb. Act as hormonal replacement therapyc. Block tissue uptake and utilization of

estrogend. Destroy any stray cancer cells in

remaining breast tissue

Family System Changes During The Family System Changes During The Childbearing CycleChildbearing Cycle

StructurePowerBoundariesAffect or feelingsIntergenerational patterns and rolesCommunication patternsCultural background and riturals

Bonding and AttachementBonding and Attachement

Bonding is affected by Maternal-Sensitive period.

Attachment is developed through out the first year of life.

Important for nursing practice: do not make inaccurate judgment, understand that childbearing is a major transition I the life of a family

Nursing intervention for the Nursing intervention for the three Phases of crisis three Phases of crisis

Precrisis: Predictable and development events in the life cycle

1. Discuss change with family structure, adding new member

2. Assess risk factors, past coping and problem solving

3. Implement health teaching4. Implement health promotion and maintenance

strategies

Nursing intervention for the Nursing intervention for the three Phases of crisisthree Phases of crisis

Crisis: Coping strategies not sufficient to deal with changes in family structure and problem in development

1. Clarify the problem2. Assist the family in going an understanding of the

situation3. Acceptance of the family4. Use appropriate interpersonal and institutional

resources5. Assess family to express feeling & ways of solving

problem

Nursing intervention for the Nursing intervention for the three Phases of crisisthree Phases of crisis

Postcrisis: Crisis has been resolved, leading to a higher, the same, or lower of family function

1. Support the family in its new strategies of resolution

2. Emphasize growth potential in solutions

3. Attempt to reverse or lessen effects of maladaptation through appropriate rehabilitative effort or therapy

Psychosocial aspects of Psychosocial aspects of childbearing Theorieschildbearing Theories

1. Psychosocial Change in the mother: Accepting the pregnancy– Symbolic meaning of the pregnancy– Self-image and body image during pregnancy

Psychosocial aspects of Psychosocial aspects of childbearing Theorieschildbearing Theories

2. Role Assumption and maternal AdaptationMaternal IdentityMaternal role attainment: Motivation for

motherhood, preparation for motherhood, conflict resolution, maternal attachment behavior, relationship with mother

Role conflict and attainment of the maternal role

Role conflict and attainment of Role conflict and attainment of the maternal rolethe maternal role

Inability to achieve the “good Mother”roleLack of knowledge and preparation for the

maternal roleEstablishing a relationship with the fetus

Maternal Ambivalence in PregnancyMaternal Ambivalence in Pregnancy No questions asked about pregnancy, labor and

delivery, infant care No interest in fetus Past negative experience with pregnancy or labor and

delivery Denial of pregnancy and fetal movement Pregnancy and parenthood interfering with life style Continue activities that may hurt the fetus (smoking or

drinking) Reporting persistent and many physical complains.

Rh ImmunizationRh Immunization

Check by Indirect Coombs test to detect antibodies in the serum that target red blood antigens to cause fetus hemolysis

Antibody titer > 1:16 indicates possibility of severe hemolytic diseases

Mother with Rh-negative: should receive Rhogam within 72 hours (any invasive procedure that may cause the mixing of the maternal blood with fetus)

Psychosocial aspects of Psychosocial aspects of childbearing Theorieschildbearing Theories

3. Psychosocial Change in the father: • Development of the father role• Participation in the childbearing cycle• Father-infant interactions and the father role • “The Couvade Syndrome”-bodily symptoms

experienced by a father during the course of his partner’s pregnancy.

4. Psychosocial Change in Sibling view

Adaptation to PregnancyAdaptation to Pregnancy

Key terms: 1. Acquaintance

2. Ambivalence

3. Attachment

4. Avoidance

5. Bonding

Mrs. H. 33 wks shared that her husband was afraid of harming the unborn baby during intercourse. Which is the best response of the nurse?

A. “Gentle vaginal intercourse is safe throughout pregnancy”

B. “each couple has a unique situation, bring your husband in for a talk with the doctor”

C. “The baby is well protected by your tissues, but if contractions occur, abstain and notify the doctor”

D. “vaginal Penetration is prohibited anyway during the last month of pregnancy because of the dangers of infection”

3

When teaching prospective fathers about pregnancy and birth, the nurse should plan to include which priority information?

A. The possible difficulties in each trimester

B. The cost of caring and raising a child

C. The normal range of feeling that may experienced in different stages of pregnancy

D. The importance of his role in the act of conception and in the determination of the sex of the fetus.

3

Pregnancy and weight gain Pregnancy and weight gain

First Trimester: 2-4 pounds (0.9-1.8 kg), 1 pound per week (0.45 kg) during 1st & 2nd trimester

Total weight gain 13.18 kg or 29 pounds

Pregnancy and NutritionPregnancy and Nutrition

Obesity: recommend to gain wt 7-11.5 kg Underweight Teenage pregnancy: low wt gain during

pregnancy, associated with LBW infant 19% of the baby wt < 2000 gram decrease 7.4% of LWB infant if wt gain improve

to 11kg (25 lbs). Frequent meal skipping and consumption of fast

food (high salt, sugar, low vit and minerals)

Risk of Obesity to pregnancy Risk of Obesity to pregnancy Gestational diabetes Urinary tract infections Inadequate weight gain Wound infection Thromboembolism PIH Fetal monitoring difficulty Prolonged labor Fetal Macrosomia Birth trauma

Question-NutritionQuestion-Nutrition

In comparison with a single fetus pregnancy, nutrition needs when there are twins much include:

a. Increased calorie intake of 300 per fetus each day

b. Low-salt foods to prevent edema

c. Additional fluid intake of 2-3 glasses per day

d. Iron and folic acid needs for 10% more per day

Warning Signs in PregnancyWarning Signs in Pregnancy Headache Altered vision: blurring, double vision, seeing spots Nausea/vomiting Epigastric pain/abdominal pain Muscular irritability/seizures Signs of infection:fever, burning in urination, flank

pain, diarrhea, Vaginal bleeding Decrease or cessation of fetal movement

Assessment for Neural Tube Assessment for Neural Tube DefectsDefects

“open” neural tube defects leak alpha-fetoprotein (AFP)

Elevate AFP level in maternal serum and amniotic fluid may indicate the fetus has neural tube defects

Amniocentesis Amniocentesis

Performed around 15-18 weeks of gestation to identify genetic abnormality

Risk: 1. Trauma to the fetus, placenta, umbilical cord,

or maternal structures

2. Infection

3. Premature labor and spontaneous abortion

AmniocentesisAmniocentesis

Warning signs after receiving amniocentesis:

1. Body temperature elevation

2. Fluid leaking from the vaginal

3. Mild Cramping and abdominal aching

4. Decreased fetal movement

Chorionic Villus SamplingChorionic Villus Sampling

To detect genetic or chromosomal defectsCan be done in early pregnancy 9-10 weeks

gestationRisk: miscarriage 3.7-7.7%, 1.7%

discrepancy of result between villus karyotype and fetus, rupture amniotic sac, chorioamnionitis, oligohydramnios, intrauterine growth retardation

The Nonstress test The Nonstress test

Check fetus well-beingCheck fetal movement in relation to fetal

heart rate acceleration Reactive: HR acceleration with fetus

movement Non reactive: no HR acceleration with fetus

movement

Genetic Problem Genetic Problem

Autosomal Recessive Disorders: 25% of the Risk of passing the disorder to each of their

offspring. 1:4 chance of demonstrating the disorder, 50% change of being a carrier to the recessive trait, each child has 25% chances of not having the diseases and not being a carrier

-Cystic fibrosis, PKU, Sickle cell anemia,-X-linked disorders: Hemophilia, color blindness,

G6PD

Nursing and family with Nursing and family with Genetic disordersGenetic disorders

Perform Karyotype examinationGenetic Counseling-support for decision

making Genetic screen for potential risk

Assisting the client to cope with Assisting the client to cope with First-Trimester DiscomfortsFirst-Trimester Discomforts

Nausea/vomiting-morning sickness Ptyalism “excess saliva in the mouth” Altered taste Bleeding gums Breast tenderness Urinary frequency Nasal stuffiness and Epistaxis Increased vaginal secretion Fatigue

Ensure Safety and removing Ensure Safety and removing barriers to carebarriers to care

Promoting client safety: home, work, lifestyle, environment, danger/warning signs of pregnancy

Removing barriers: Social Economic factors, lack of insurance, inability to pay, lack of free prenatal service, limit access to prenatal care for economically poor women, limited or expensive transportation, small children, cultural

Psychologic changes and concerns Psychologic changes and concerns of a mother at 2of a mother at 2ndnd Trimester Trimester

Aware of that the pregnancy can be recognized by others

Acceptance of pregnancy Maternal role attainment: fetus movement fosters

internalization and fantasy Fantasies: binding to infants Relationship with mother Body image: begins to view fetus as separate form

own body, change the perception of body boundary as protective barrier to fetus

QuestionQuestion

The nurse should assess for which developmental task of the pregnant women in her third trimester?

a. Bonding to the fetus in preparation for birth

b. Accepting the fetus as a wanted responsibility

c. Understanding the baby is an independent being

d. Preparing to separate from the fetus through the birth process

Question-DM motherQuestion-DM mother

The nurse teaches the newly pregnant diabetic the importance of self glucose monitoring in the first trimester to prevent:

a. Hypoxia in the fetus

b. The onset of diabetes in fetus

c. Unusually large fetal development

d. Teratogenic effects of hyperglycemia

Question- Preterm LaborQuestion- Preterm Labor

Magnesium Sulfate may be prescribed as a tocolytic drug because one of the expected actions is:

a. Promoting diuresis

b. Lowering blood pressure

c. Inducing sedation and rest

d. Promoting smooth muscle relaxation

Pain during labor Pain during labor

Analgesia: demerol (meperidine) Sedative: Seconal and Nembutal Narcotic analgesics: Fentanyl, Stabol Anesthesia: Marcaine (Bupavacaine)

Alfenta (Alfentani)

Epidural Block Epidural Block

Give to women in 2-4 cm Cx dilation Giving anesthesiologist into epidual space at L-2,

L-3, L-4 or L-5 Provide pain relief in lower part of body Labor stimulation by Oxytocin may need Prevent Hypotensive effect (500-1000 ml Lactated

Ringer’s) Monitoring uterus contraction and fetus condition

Side Effects of Epidural Side Effects of Epidural Analgesia Analgesia

Respiratory depression in newborn (Narcan)Pruitus (itching)Nausea and vomiting Urinary retentionHypotensive Affect labor process, unable to push during

second stage of labor (assessment important)

QuestionQuestion

A Client has received an effective dose of epidural anesthesia. The IV rate is 250 ml/hour and position is semi-Fowler’s. Her blood pressure has dropped significantly. The first nursing intervention is to:

a. Slow the rate of IV infusion to avoid overloadb. Retake the BP, initial hypotension is expectedc. Begin oxygen by face mask, lower head, elevate

legs. d. Call back anesthesiologist to deal with the condition

Induction or Augmentation of Induction or Augmentation of Labor Labor

Induction: starting labor artificially by oxytocin

Augmentation: stimulation of labor once it has begun naturally.

Amniotomy: color of the amniotic fluid Assess risk: frequency of contraction,

maternal tolerance, pain, fetus well-being, discomfort, progress of labor, complication

Lamaze Technique QuestionLamaze Technique Question

The nurse teaching the Lamaze technique evaluates her success when the couple do the following:

a. Break the fear/tension/pain cycle

b. Bond successfully with the newborn

c. Use positive feedback with each other during labor

d. Maintain control during labor by their techniques of breathing and relaxation

QuestionQuestion (pain and childbirth class) (pain and childbirth class)

In developing childbirth classes the nurse plans to include techniques that normally minimize pain perception, which of these are inappropriate?

a. Using muscle relaxation methods

b. Invalidating the perception of pain

c. Refocusing attention on another subject

d. Implementing anxiety reduction techniques

In developing childbirth classes the nurse plans t include techniques that normally minimize pain perception, which of these are inappropriate?

a. Using muscle relaxation methods

b. Invalidating the pain perception

c. Refocusing attention on another subject

d. Implementing anxiety reduction techniques

Vaginal Birth After Cesarean Vaginal Birth After Cesarean Section (VBAC)Section (VBAC)

Repeat CS in USA 80% Fear of weakening the uterine scare Twice Maternal Risk in C/S than in Vaginal birth Qualification: primary cesarean not due to pelvic

factors. “Classic uterine incision???” Support of staff and women’s desire to have

vaginal birth are optimal factor for trying VBAC

QuestionQuestion

When membranes rupture spontaneously during labor, the nurse at the bedside must immediately:

a. Monitor fetal heart rate b. Change the bed ped and give peri care c. Increase the flow rate of intravenous fluidd. Report the color and consistency of the

fluid

QuestionQuestion

During labor, while lying supine in bed, Millie M. States she feels dizzy and weak, vital signs show an elevated pulse and lowered BP, the nurse should first:

a. Notify the physicianb. Check for vaginal bleedingc. Apply oxygen by mask at 10 L/mind. Rotate her to the left side-lying position

QuestionQuestion

Five hours prior to arriving at the DR, your client’s amniotic membranes ruptured, which is a priority in the nursing planning?

a. Monitoring urinary output hourly

b. Providing frequent perineal care

c. Increasing fluid intake intravenously

d. Assessing temperature at least every 2 hours

QuestionQuestion

During transitional labor, when the fetal heart rate tracing shows a drop of 50 beats for 20 seconds and the rate returns to baseline, which is the first nursing action?

a. Call for physician at once

b. Turn client toward the left lateral position

c. Position client to relieve pressure on the cord

d. Do nothing, continue to observe since there is a rapid return to baseline

Postpartum Lactation Postpartum Lactation

Colostrum: contain Immunoglobulins G and A (Ig G, Ig A) to protect newborn’s gastrointestinal System

Secretion stage: prolactin hormone Let-down reflex: Neurohormonal Reflex

primary responds to infant’s sucking, posterior pituitary gland secretes oxytocin.

Question – Question – hypoglycemia newborn hypoglycemia newborn

Which would indicate to the nurse that the newborn may be hypoglycemic?

a. Hyperthemia with flushed skin

b. Residual tremors after movement

c. Vigorous sucking on nipple or on fist

d. Frequent loose stools

Please Keep your good work Please Keep your good work and study hard, maternal-and study hard, maternal-

infant nursing is an interesting infant nursing is an interesting subject for you to learn!subject for you to learn!